静脉溶栓桥接血管内取栓治疗对急性心源性脑卒中的功能结局疗效分析

Efficacy of intravenous thrombolysis bridging endovascular thrombectomy on functional outcome of patients with acute cardioembolic stroke

目的探讨静脉溶栓桥接血管内取栓治疗(endovascular thrombectomy,EVT)对急性心源性脑卒中患者临床功能结局的影响。方法回顾性纳入2017年1月—2021年12月四川大学华西医院神经内科收治的发病24 h内接受EVT的心源性脑卒中患者,根据是否接受静脉溶栓治疗分为桥接治疗组和直接EVT组。主要结局指标为3个月不良功能结局,即改良Rankin量表(modified Rankin Scale,mRS)评分3~6分;次要结局指标包括在院期间颅内出血和3个月内死亡。采用多因素logistic回归校正混杂因素,分析干预措施对3个月功能结局的影响。结果共纳入患者285例,其中女性174例(61.1%),年龄的中位数(下四分位数,上四分位数)为74(64,80)岁,发病至入院时间的中位数(下四分位数,上四分位数)4.0(3.0,5.0)h。与直接EVT组(n=202)相比,桥接治疗组(n=83)患者3个月功能结局不良的比例更低(55.4%vs.68.3%,P=0.039),两组间颅内出血发生率(47.0%vs.39.6%,P=0.251)和3个月死亡率(20.5%vs.30.7%,P=0.080)差异无统计学意义。校正年龄、美国国立卫生研究院卒中量表评分、发病至入院时间等因素后,多因素logistic回归分析显示桥接治疗与直接EVT相比可改善3个月功能结局[比值比=0.482,95%置信区间(0.249,0.934),P=0.031]。结论对于急性心源性脑卒中患者,静脉溶栓桥接EVT与直接EVT相比,可改善患者3个月功能结局,且不增加颅内出血风险。

Objective To investigate the clinical efficacy and safety of intravenous thrombolysis bridging endovascular thrombectomy(EVT)in patients with acute cardioembolic stroke.Methods We retrospectively included patients with cardioembolic stroke who were admitted within 24 h after onset of stroke symptoms and had received EVT in the Department of Neurology,West China Hospital of Sichuan University between January 2017 and December 2021.Based on whether they had received intravenous thrombolysis,the patients were divided into bridging therapy group and direct EVT group.The primary outcome was unfavorable outcome by 3 months,defined as a modified Rankin Scale(mRS)score of 3 to 6.The secondary outcomes included intracranial hemorrhage during hospitalization and 3-month death.Multivariable logistic regression was performed to assess the treatment effect on the primary outcome after adjusting for confounding factors.Results A total of 285 patients were enrolled.Among them,174(61.1%)were female,the median age was 74 years(interquartile range 64-80 years),and the median time from stroke onset to admission was 4.0 h(interquartile range 3.0-5.0 h).Compared to patients in the direct EVT group(n=202),patients in the bridging therapy group(n=83)had a lower rate of unfavorable functional outcome(55.4%vs 68.3%,P=0.039)by 3 months,while the incidences of intracranial hemorrhage(47.0%vs.39.6%,P=0.251)and 3-month death(20.5%vs.30.7%,P=0.080)were comparable between the two groups. After adjusting for confounding factors, the bridging therapy improved 3-monthfunctional outcomes over direct EVT [odds ratio=0.482, 95% confidence interval (0.249, 0.934), P=0.031]. Conclusion In patients with acute cardioembolic stroke, intravenous thrombolysis bridging endovascular treatment can significantlyimprove 3-month functional outcomes without increasing the risk of intracranial hemorrhage.